Integrated care for older people with cancer: a primary care focus
Authors: Wee Kheng Soo, Vicky Yin, Jane Crowe, Heather Lane, Christopher B Steer, Pēteris Dārziņš, Ian D Davis
Journal: The Lancet Healthy Longevity (2023)

Estimates from a 2023 study indicate that cancer will continue to grow as a leading cause of health and economic burden alongside global population ageing.1Chen S Cao Z Prettner K et al.Estimates and projections of the global economic cost of 29 cancers in 204 countries and territories from 2020 to 2050.JAMA Oncol. 2023; (published online Feb 23.)https://doi.org/10.1001/jamaoncol.2022.7826Crossref Scopus (2) Google Scholar Consequently, health-care providers, including primary care teams, will increasingly face substantial challenges in caring for older people with cancer who have evolving, complex, and specific needs. More than 60% of new cancer diagnoses occur in adults aged 65 years and older in high-income countries, underpinning the importance of empowering primary health-care providers (including general practitioners, community nurses, allied health professionals, and pharmacists) to provide high-quality care to this at-risk population.2Pilleron S Sarfati D Janssen-Heijnen M et al.Global cancer incidence in older adults, 2012 and 2035: a population-based study.Int J Cancer. 2019; 144: 49-58Crossref PubMed Scopus (280) Google Scholar Nevertheless, geriatric oncology remains peripheral in the awareness of primary health-care providers. Therefore, raising awareness of the growing importance of geriatric oncology and fostering collaboration between primary health-care providers and oncogeriatric teams is essential to ensure optimal care for older people with cancer. Geriatric oncology has emerged as a specialised field in medicine that is dedicated to improving the quality of care and health outcomes for older people with cancer. The well documented history of geriatric oncology can be traced back to the 1980s, with recognition of the specific needs of this older population.3DuMontier C Sedrak MS Soo WK et al.Arti Hurria and the progress in integrating the geriatric assessment into oncology: Young International Society of Geriatric Oncology review paper.J Geriatr Oncol. 2020; 11: 203-211Summary Full Text Full Text PDF PubMed Scopus (20) Google Scholar The geriatric assessment, a multidimensional evaluation of an older person's medical, functional, nutritional, and psychosocial status, is central to these efforts. This assessment enables clinicians to identify ageing-associated vulnerabilities and frailty levels, guiding cancer treatment and optimising person-centred factors through personalised, supportive care aligned with the preferences and priorities of patients.4Soo WK King MT Pope A Parente P Dārziņš P Davis ID Integrated Geriatric Assessment and Treatment Effectiveness (INTEGERATE) in older people with cancer starting systemic anticancer treatment in Australia: a multicentre, open-label, randomised controlled trial.Lancet Healthy Longev. 2022; 3: e617-e627Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 5Hamaker M Lund C Te Molder M et al.Geriatric assessment in the management of older patients with cancer—a systematic review (update).J Geriatr Oncol. 2022; 13: 761-777Summary Full Text Full Text PDF PubMed Scopus (20) Google Scholar A growing body of level 1 evidence from randomised controlled trials has shown that geriatric assessment combined with personalised interventions can improve meaningful outcomes for older people with cancer, including treatment tolerance and completion, quality of life and functioning, health-care use, and communication about care planning and ageing-related issues.4Soo WK King MT Pope A Parente P Dārziņš P Davis ID Integrated Geriatric Assessment and Treatment Effectiveness (INTEGERATE) in older people with cancer starting systemic anticancer treatment in Australia: a multicentre, open-label, randomised controlled trial.Lancet Healthy Longev. 2022; 3: e617-e627Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 5Hamaker M Lund C Te Molder M et al.Geriatric assessment in the management of older patients with cancer—a systematic review (update).J Geriatr Oncol. 2022; 13: 761-777Summary Full Text Full Text PDF PubMed Scopus (20) Google Scholar Leading organisations such as the International Society for Geriatric Oncology and the American Society of Clinical Oncology now recommend the integration of geriatric assessments into cancer care for older people. This recommendation has led to the development of various oncogeriatric service models, including those led by nurses or allied health professionals, multidisciplinary teams (with or without geriatricians), geriatrician clinics for patients with cancer, and dedicated oncology clinics for older individuals. Primary health-care providers have always been at the forefront of providing holistic, longitudinal care for older people. The similarities between geriatric assessment and health assessments conducted by primary health-care providers reflect the effect of geriatric medicine and primary care in advancing principles of quality care for older individuals. These principles include a comprehensive and systemic approach, multidimensional assessment of medical and non-medical health domains, and multidisciplinary interventions to address assessed needs.6Veronese N Custodero C Demurtas J et al.Comprehensive geriatric assessment in older people: an umbrella review of health outcomes.Age Ageing. 2022; 51afac104Crossref Scopus (10) Google Scholar Gradual integration of these principles is occurring across various areas of health care, creating more age-friendly systems that address the key tenets: what matters, medication, mentation, and mobility.7Fulmer T Patel P Levy N et al.Moving toward a global age-friendly ecosystem.J Am Geriatr Soc. 2020; 68: 1936-1940Crossref PubMed Scopus (30) Google Scholar However, clinical trials have shown that oncogeriatric models of care provide better outcomes than routine care, highlighting the need for further action. WHO's Integrated Care for Older People initiative, launched in collaboration with the UN Decade of Healthy Ageing (2021–2030), recognised the need for a more comprehensive, coordinated approach in primary care, including setting person-centred goals, screening for loss of intrinsic capacity, and assessing health and social care needs to develop a personalised care plan.8WHOIntegrated Care for Older People (ICOPE): guidance for person-centred assessment and pathways in primary care. World Health Organization, Geneva2019Google Scholar The intrinsic capacity domains—cognition, mobility, nutrition, vision and hearing, and mood—are remarkably aligned with geriatric assessment domains, displaying convergence in these assessment processes. Despite the acknowledged importance of primary care in the integrated oncogeriatric approach, there is a dearth of research that involves primary care in current oncogeriatric models.9Tremblay D Charlebois K Terret C Joannette S Latreille J Integrated oncogeriatric approach: a systematic review of the literature using concept analysis.BMJ Open. 2012; 2e001483Crossref PubMed Scopus (23) Google Scholar This paucity of data might be due to several factors, including primary health-care providers being excluded from cancer multidisciplinary teams or lacking resources to effectively manage the complex needs of this population. Funding constraints, time limitations, competing demands, weak linkages among health-care services, interdiscplinary silos in health care, and suboptimal enablement from health-care systems or policies can also serve as barriers. Nevertheless, these challenges represent opportunities for better communication, collaboration, and integration across all health-care teams providing care for older people with cancer—primary care, oncology, haematology, geriatrics, rehabilitation, and palliative care (figure). We believe that the integration of care across the health systems continuum is essential to lessen the burden of cancer in older people. Greater long-term investment in education, clinical practice, research, and collaborative partnership is needed to achieve this goal, by leveraging technology and innovative care models.10Extermann M Brain E Canin B et al.Priorities for the global advancement of care for older adults with cancer: an update of the International Society of Geriatric Oncology Priorities Initiative.Lancet Oncol. 2021; 22: e29-e36Summary Full Text Full Text PDF PubMed Scopus (35) Google Scholar By embracing the principles of geriatric assessment and working collaboratively, health-care providers can offer personalised, comprehensive care that prioritises patients' needs, moving the health-care system closer to realising the vision of integrated care for older people with cancer. IDD was supported by a National Health and Medical Research Council Practitioner Fellowship (APP1102604) during the preparation of this Comment, and reports unpaid advisory board roles at Astellas, AstraZeneca, Eisai, Ipsen, Merck/Pfizer, MSD, Pio Therapeutics, Roche, Telix Therapeutics, and Xennials Therapeutics. WKS reports grants from Monash University and Eastern Health during the preparation of this Comment, and has received honoraria from Janssen, unrelated to the submitted work. CBS has received honoraria from Janssen, GlaxoSmithKline, AstraZeneca, Eisai, Ipsen, Novartis, Sanofi, MSD, and Bristol Myers Squibb, unrelated to the submitted work. All other authors declare no competing interests.